A modified bronchial anastomosis technique for lung transplantation

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Presentation transcript:

A modified bronchial anastomosis technique for lung transplantation Carsten Schröder, MD, Frank Scholl, MD, Emmanuel Daon, MD, Andrea Goodwin, RN, MSN, William H Frist, MD, John R Roberts, MD, Karla G Christian, MD, Mathew Ninan, MD, Aaron P Milstone, MD, James E Loyd, MD, Walter H Merrill, MD, Richard N Pierson, MD The Annals of Thoracic Surgery Volume 75, Issue 6, Pages 1697-1704 (June 2003) DOI: 10.1016/S0003-4975(03)00011-0

Fig 1 Distribution of cases (with completed follow-up) by year and anastomotic technique for Vanderbilt lung transplant program over the study period between November 1990 and February 2001. Checkered bars = classic telescoping technique; solid bars = modified telescoping technique. The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 2 The classic telescoping technique (a) leaves a devascularized shelf of bronchial tissue protruding into the lumen (b, arrow) using just U stitches. A running suture is used for the membranous posterior wall. The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 3 The modified telescoping technique (c) uses just three U stitches (a) at 0, 90 and 180 degrees and two or three figure-of-eight sutures in between (b) to coapt the walls properly. A running suture is used for the membranous posterior wall. The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 4 Severe stenosis rate (> 30% narrowing relative to caliber of proximal native airway) is significantly lower using the modified telescoping technique. Statistical analysis by χ2 for a trend using all grades of stenosis. *p less than 0.03. Checkered bars = classic telescoping technique; solid bars = modified telescoping technique. The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 5 Severe and moderate airway instability rate is lower through the whole observation period when the modified telescoping technique is used. Statistical significance is reached only for the initial observation. *p less than 0.01. Checkered bars = classic telescoping technique; solid bars = modified telescoping technique. The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 6 Devascularization in the initial observation (4 to 14 days after lung transplantation) shown as percentage of devascularized anastomotic circumference. The modified telescoping technique is associated with reduced devascularization (p = 0.039, overall). In the severe (80% to 100%, p < 0.043 single tailed) and moderate (50% to 70%) grades the modified technique shows lower rates of devascularization. The incidence of mild (20% to 40%) grades of devascularization is significantly higher (p = 0.006) using the modified technique. *p less than 0.05. Checkered bars = classic telescoping technique; solid bars = modified telescoping technique. The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 7 Kaplan-Meier survival curves for the modified (n = 75) and classic (n = 70) telescoping technique for the first 5 years after transplantation. Survival is significantly improved in the modified telescoping group. (+ = censored.) The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)

Fig 8 Two-stage Cox proportional hazard model to analyze the influence of anastomotic technique and type of postoperative infection. In addition to infection in the first 90 days in 118 patients with completed airway follow-up, the analysis also took into account sex, age, preoperative steroids, cytomegalovirus (CMV) mismatch, single versus double lung transplantation, and cardiopulmonary bypass usage. Modified anastomotic technique was associated with better outcomes for each category of infection. Although infrequent, non-CMV viral infection was associated with poor outcome regardless of anastomotic technique. (Types of infection: heavy dashed line = none; dash-dotted line = Aspergillus; light dashed line = bacterial; solid line = viral.) The Annals of Thoracic Surgery 2003 75, 1697-1704DOI: (10.1016/S0003-4975(03)00011-0)